UTI For surgical board

1. UTIFor surgical board Dr. Mohamed El-Shazly M.D. (Urology)

2. Urinary tract infections (UTIs) are among the most prevalent infectious diseases, with a substantial financial burden on society.

3. In the USA, UTIs are responsible for over 7 million physician visits annually, including more than 2 million visits for cystitis. • Approximately 15% of all community-prescribed antibiotics in the USA are dispensed for UTI, at an estimated annual cost of over US $1 billion (Naber et al., 2010)

4. The gold standard for the diagnosis of a urinary tract infection is the detection of the pathogen in the presence of clinical symptoms. The pathogen is detected and identified by urine culture (using midstream urine). This also allows an estimate of the level of the bacteriuria.

5. The number of bacteria is considered relevant for the diagnosis of a UTI. • In 1960, Kass developed the concept of significant bacteriuria (> 105 cfu/mL) in the context of pyelonephritis in pregnancy (Kass, 1960).

6. > 103 cfu/mL of uropathogens in a mid-stream sample of urine (MSU) in acute uncomplicated cystitis in women. • > 104 cfu/mL of uropathogens in an MSU in acute uncomplicated pyelonephritis in women. • > 105 cfu/mL of uropathogens in an MSU in women, or > 104 cfu/mL uropathogens in an MSU in men,or in straight catheter urine in women, in a complicated UTI.

7. In a suprapubic bladder puncture specimen, any count of bacteria is relevant

8. Evaluation • Effective management begins by obtaining a careful history with attention given to current symptomatology, prior episodes of documented UTI, and risk factors that can initiate (e.g. urethral catheterization or sexual intercourse) or complicate (diabetes mellitus or pregnancy) a UTI.

9. Proper collection • A midstream voided specimen is generally adequate, but urethral catheterization or suprapubic aspiration may be necessary in an individual who cannot produce a clean specimen.

10. Since UTI is a host inflammatory response to bacterial invasion, urinalysis will reveal pyuria (the presence of white blood cells in the urine) and bacteriuria. • If there is bacteriuria with no pyuria in an asymptomatic patient, an infection is not present and therapy is usually not necessary.

11. PATHOGENESIS • Complex interactions between an organism, the environment, and the potential host.

12. The most common causative pathogen is Escherichia coli, which is responsible for 85% of infections in ambulatory patients and 50% of nosocomial infections. Proteus mirabilis, Klebsiella pneumonia, and Enterococcus fecalis, are the next most frequent isolates. (Patton, 1991)

13. Pathogenesis • Most infections are caused by retrograde ascent of bacteria from the fecal flora via the urethra to the bladder and kidney • Haematogenous infection of the urinary tract is restricted to a few relatively uncommon microbes, such as Staphylococcus aureus, Candida sp., Salmonella sp. and Mycobacterium tuberculosis, which cause primary infections elsewhere in the body.

14. There are urinary pathogen virulence factors that promote adherence to mucosal surfaces and subsequent infection. The bacteria usually express fimbriae or pili which mediate adherence to the epithelial cell receptors

15. Host factors such as the epithelial cell receptivity are also important in the infection process. For example, E. coli bound to vaginal epithelial cells from healthy controls less avidly than to vaginal epithelial cells from women with recurrent UTIs (Fowler et al., 1977)

16. A single insertion of a catheter into the urinary bladder in ambulatory patients results in urinary infection in 1-2% of cases. Indwelling catheters with open-drainage systems result in bacteriuria in almost 100% of cases within 3-4 days

17. CLASSIFICATION • Uncomplicated UTI • Complicated UTI • Urosepsis

18. Uncomplicated UTIs in adults • Acute, uncomplicated UTIs in adults include episodes of acute cystitis and acute pyelonephritis in otherwise healthy individuals.

19. The spectrum of aetiological agents is similar in uncomplicated upper and lower UTIs, with E. coli the causative pathogen in 70-95% of cases and Staphylococcus saprophyticus in 5-10%.

20. Acute uncomplicated cystitis in premenopausal, non-pregnant women • Urine cultures are recommended for those with: (i) suspected acute pyelonephritis; (ii) symptoms that do not resolve or recur within 2-4 weeks after the completion of treatment;

21. A colony count of > 103 cfu/mL of uropathogens is microbiologically diagnostic

22. Cotrimoxazole 160/800 mg bid for 3 days or trimethoprim 200 mg for 5 days • Alternative antibiotics are ciprofloxacin 250 mg bid,

23. Acute uncomplicated pyelonephritis in pre-menopausal, non-pregnant women Clinical picture: Diagnosis : Colony counts > 104 cfu uropathogen/mL ultrasound should be performed to rule out urinary obstruction or renal stone disease

24. Fever > 3 days (CT), an excretory urogram, or (DMSA) scan, to rule out urolithiasis, renal or perinephric abscesses.

25. As first-line therapy in mild cases, an oral fluoroquinolone for 7 days • severe cases should be admitted to hospital and treated with parenteral fluoroquinolone (ciprofloxacin or levofloxacin), a third-generation cephalosporin • Treatment should be continued for 1-2 weeks with oral antibiotics

26. Recurrent (uncomplicated) UTIs in women • Long-term, low-dose prophylactic antimicrobials taken at bedtime • Prophylactic alternative methods include immunotherapy and probiotic therapy, • acidification, and cranberry juice

27. UTIs in pregnancy • Most symptomatic UTIs in pregnant women present as acute cystitis • The prevalence of asymptomatic bacteriuria in American, European and Australian studies varies between 4% and 7% while 20-40% of women with asymptomatic bacteriuria will develop pyelonephritis during pregnancy. • Treatment of asymptomatic bacteriuria lowers this risk

28. UTIs in pregnancy For a recurrent UTI, low-dose cephalexin (125-250 mg) or nitrofurantoin (50 mg) at night is recommended for prophylaxis against re-infection

29. For acute pyelonephritis, second- or third-generation cephalosporins, an aminoglycoside, or an aminopenicillin plus a BLI may be recommended antibiotics • During pregnancy, quinolones, tetracyclines and TMP are contraindicated in the first trimester

30. Right hydronephrosis with UTI, a ureteral stent may be indicated and Antimicrobial prophylaxis should be considered until delivery

31. UTIs in post-menopausal women In the case of a recurrent UTI, urological or gynaecological evaluation should be performed in order to eliminate a tumour, obstructive problems, detrusor failure or a genital infection

32. UTIs in post-menopausal women In post-menopausal women with a recurrent UTI, therapy with intravaginal oestriol is able to reduce significantly the rate of recurrences

33. URINARY TRACT INFECTIONS IN CHILDREN In the first year of life, mostly the first 3 months, UTI is more common in boys (3.7%) than in girls (2%), after which the incidence changes, being 3% in girls and 1.1% in boys

34. Paediatric UTI is the most common cause of fever of unknown origin in boys less than 3 y

35. short courses are not advised and therefore treatment is continued for 5-7 days and longer. If the child is severely ill with vomiting and dehydration, hospital admission is required and parenteral antibiotics are given initially.

36. Investigation should be undertaken after two episodes of a UTI in girls and one in boys ears Objective is to rule out the unusual occurrence of obstruction, vesicoureteric reflux (VUR) and dysfunctional voiding

37. Voiding cystourethrography (VCU) is the most widely used radiological exploration for the study of the lower urinary tract and especially of VUR

38. Even in the presence of normal Ultrasonography, Up to 23% of these patients may reveal VUR

39. Treatment Treatment has four main goals: 1. Elimination of symptoms and eradication of bacteriuria in the acute episode 2. Prevention of renal scarring 3. Prevention of a recurrent UTI 4. Correction of associated urological lesions.

40. Vesicoureteric reflux is treated with long-term prophylactic antibiotics. Endoscopic treatment Surgical re-implantation

41. Recurrent UTI may be subclassified into three groups 1-Unresolved infection: subtherapeutic level of antimicrobial, non-compliance with treatment, malabsorption, resistant pathogens.

42. 2• Bacterial persistence: may be due to a nidus for persistent infection in the urinary tract. Surgical correction or medical treatment for urinary dysfunction may be needed. 3• Reinfection: each episode is a new infection acquired from periurethral, perineal or rectal flora

43. Factors that suggest a potential complicated UTI • The presence of an indwelling catheter, stent or splint (urethral, ureteral, renal) or the use of intermittent bladder catheterization • A post-void residual urine of > 100 mL • An obstructive uropathy of any aetiology, e.g. bladder outlet obstruction (including neurogenic urinary bladder), stones and tumour

44. Vesicoureteric reflux or other functional abnormalities • Urinary tract modifications, such as an ileal loop or pouch • Renal insufficiency and transplantation, diabetes mellitus and immunodeficiency

45. Catheter Fever General aspects 1. Written catheter care protocols are necessary. 2. Health care workers should observe protocols on hand hygiene and the need to use disposable gloves between catheterised patients

46. 3. An indwelling catheter should be introduced under antiseptic conditions. 4. Urethral trauma should be minimised by the use of adequate lubricant and the small catheter calibre. 5- The duration of catheterisation should be minimal.

47. SEPSIS syndrome IN UROLOGY (UROSEPSIS) The systemic inflammatory response syndrome, known as SIRS (fever or hypothermia, hyperleucocytosis or leucopenia, tachycardia, tachypnoea), is recognized as the first event in a cascade to multi-organ failure.

48. Sepsis or septic shock are present, though the prognosis of urosepsis is globally better than sepsis due to other infectious sites.

49. The treatment of urosepsis calls for the combination of adequate life-supporting care, appropriate and prompt antibiotic therapy, adjunctive measures (e.g. sympathomimetic amines, hydrocortisone, blood Glucose control, recombinant activated protein C) and the optimal management of urinary tract disorders

50. Sepsis syndrome in urology remains a severe situation with a mortality rate as high as 20-40%.